Archive for the 'Health Care’s Broke' Category

I hope you’ve enjoyed the series and it’s made you think a bit about health care, health policy, and how difficult it is to come up with solutions to our health care problems. I appreciate the civil discussion and debate, and continue to welcome any other feedback!

A few topics I wanted to cover but didn’t have time to:

Science education – If we want our patients to understand medicine and the science behind it, they need to understand (and accept) the basic tenets of science — randomized studies, for example — and perhaps that’s where we’re failing. People seem to have a miraculous ability to accept the science they have chosen to believe (antibiotics for bacterial infections, germ theory) while ignoring rigorous science that doesn’t fit with their world view (thiomersal is not responsible for autism).

Patient Autonomy – Has it gone too far? By asking patients or their decision-makers to decide, “Do you want to keep trying failing treatments or terminate care,” perhaps we’re putting too much decision-making in the hands of a person who clearly doesn’t want to feel responsible for “pulling the plug” on their mother (who would?)? While no one wants to die or wants a loved one to die, is it fair to other people who have a better chance of hope of recovery to take up a hospital bed to treat a demented 95 year-old man who won’t get any better?

And many more!

On that note, it’s been a pleasure writing about my journey through medical school, and I appreciate everyone who’s joined me and supported me along the way.

I’m heading to Xela, Guatemala (aka Quetzaltenango) tonight for two months with Asociación Pop-Wuj to do some intensive Spanish and medical Spanish training (as well as seeing their cigar-smoking saint, Maximón, and hiking and exploring) before heading back to be in a friend’s wedding. I likely won’t be blogging much, but hey, who knows. Since I now have an official job as a doctor (scary), I’ll be wrapping Over My Med Body up in time for Graduation in June. Stay safe and healthy and I’ll see you on the flip side!

You knew it was coming, my single-payer post. It’s a nice wrap-up to the series. (I figured since I was agreeing with KevinMD and Panda so much I had to do something.)

I could make my argument for single-payer in any number of ways, but you’ve probably already heard them:

Human dignity. Everyone should have health care as a human right. That people deserve health care, and as a wise family practice doc from Idaho wrote, the uninsured pay for their health care with their dignity. That almost all of the uninsured and underinsured are hardworking, tax-paying people who either make “too much” money to qualify for programs for the poor like Medicaid or don’t make enough for their employers to also provide health insurance. Or that health insurance is often way too expensive for their families, or even if they bought health insurance, it wouldn’t cover their major problems, like their kid’s asthma (sorry, pre-existing condition).

We the taxpayers and insured are already paying for the uninsured in the form of higher taxes, higher insurance premiums, and longer waits for our own health care (remember, we’re all connected). Since we’re humane enough to have EMTALA and not let people die on the streets, people are going to get some level of care, no matter how poorly planned, poorly organized, or terribly chaotic it is. We might as well just pay for everyone and get a better bang for our buck, no? Isn’t that the American way, to at least get a good deal?

Economic growth is seriously stunted by our current non-system. Why did the Jelly Belly factory cross the border? To get cheaper health care costs in Canada. (True story.) In our global economy, take a look at any American industry and you’ll see our health care costs stick out like a sore thumb–and this makes American companies have higher costs and are therefore less competetive. US automakers currently pay more for their employees’ health insurance than the steel to build their cars (which is why renowned health care economist Uwe Reinhardt refers to the American car companies as health insurance providers financed by selling cars).
Many people–especially potential small business owners/entrepreneurs–simply forget any aspirations they have of starting their own business because of health care costs. If you quit your job and lose your health insurance and then get sick, you’re screwed. So there’s an incentive to stay in a job one hates, no matter how unproductive the worker is, because it provides them with health insurance.

We already ration care. Many people cite a valid concern that single-payer would lead to ominous “health care rationing.” They do not realize that we already ration care: based on ability to pay, not health care need.

Single-payer will save us money. Take a look at any proposed health care scheme, as many economists have in multiple previous studies (California Health Care Options Project, The Vermont Single-Payer Study, The Maryland Single-Payer Study, Massachusetts Health Care Studies, and Maine’s Single-Payer Microsimulation. Just to be clear, these analyses were done by The Lewin Group and Mathematica Consulting, two economic analyst groups. Not single-payer supporters), and you’ll see that single-payer is the only one that provides health insurance to everyone while actually costing overall less. It does this by doing bulk-purchasing of products, just like you do at Sam’s Club. It also majorly simplifies administrative overhead–think of the billions spent on duplicate forms a doctor has to process from the thousands of health plans out there–and the costs of increased health care usage are still absorbed in the savings. (I’m not about to deny that Medicare has paperwork requirements, but they’d be one set of paperwork requirements only.)

Like I said. Probably really nothing new if you’ve ever read any single-payer stuff on the Internets or my blog in particular. But I’m here to propose a different, and much more important reason we should adopt single-payer. We can’t afford not to.On To Single-Payer, Part 2

America loves to medicate its problems away. Can’t sleep on a plane? Take a pil. Nervous? Take a pill. We want to be in control of our bodies to the nth degree: we’re too busy to be sick, just give us antibiotics that may or may not work; we shouldn’t be fat, just give me a pill to make it all better. We get to have our coffee any way we like it, so why shouldn’t we get to have our bodies however we want them, too?

The problem is that pills don’t work that way. Our pills are, for the most part, chemicals that muck with cells’ pre-existing hardware often by altering how a certain protein interacts with another. But because all our cells generally contain most of the same ingredients, our pills end up poisoning other unintended cells, causing collateral damage. (This is why chemo kills cancer but has such severe side effects: it works by killing cells that grow rapidly, as many cancers do, but other body cells grow rapidly too–the hair, the gut, the immune system–and so these cells die too.)

It would be much cheaper for society–and healthier–to prescribe “exercise” or “a healthier diet.” Often this is what we physicians do prescribe, but our patients do not (and often cannot) follow through. Exercise, diet, and other things that can have a major impact on health are often lumped together as simply “lifestyle,” and are often viewed as individual preference and choice. It’s often easier to simply prescribe a drug (even though we realize that lifestyle changes would be much prefered). The Happy Hospitalist often rants about this–how much money would we save if people just ate healthier and exercised instead of taking pills?

Well, people should eat better, have less stress, and exercise more. Duh.

Some of this might be improved by better city planning and social policy: encouraging walking and public transportation, changing our farm subsidies around to encourage cheaper produce and more access to it.

But the larger social change (and therefore, less likely one) is changing our lifestyles. If you want people to eat better and exercise more, you have to give them more time to do these things. In the short run, sure, it’s easier to medicate the problem away. But in the long-term, I think healthier lifestyles beat polymedicated Americans anyday.

Again, this would require massive changes in our culture and society. To lose our obsession on material goods and consumerism, to realize that taking care of ourselves should take priority over a nicer car or more stuff. To have a greater distribution of wealth. But I illustrate this “solution” more to suggest how difficult it might be to make inroads in this prescription mania in America than anything else.

Primary care in this country is dying. There are fewer available primary care doctors in this country, as more and more physicians either go directly into specialty care or choose a specialty after completing one of the primary care tracks (internal medicine, pediatrics, family practice, obstetrics and gynecology).

Why is this a problem? Primary care is the foundation of a health care system. Most problems and illnesses most people have can reliably be treated by a primary care doctor. When Iran wanted to develop its health care infrastructure, for example, they asked a family practice doctor to fly over and work with their medical leaders, not a urologist or cardiologist. If you don’t have primary care in your health care system, you end up way overpaying for unnecessary specialist care (think of sending a person to a urologist if they have a urinary tract infection instead of going to their family doctor, for example). You also can’t effectively triage people and get them to the right doctor. If someone is short of breath, do you send them to the cardiologist, the pulmonologist, the allergist, the rheumatologist, or the infectious disease doctor? Lose primary care and you lose the basis for your medical decision tree.

And it’s not just that physicians aren’t going into primary care, it’s that primary care doctors are often actually stopping practicing primary care. They find there are other ways they can make better money (or lose less money). When you see this in a health care system–that DOCTORS are quitting medicine, for whatever reason–think bad, bad health care system future.

Why is this happening? A number of reasons, but I’d argue it depends on who you ask:

Primary care doctors: Money. All about money. Low reimbursement rates for seeing patients (especially compared to specialists who get paid much more handsomely for procedures). Long hours, relatively low pay compared to your colleagues. Lots of paperwork.

Medical students: Time. All about time. 15 minutes to see each and every patient, no matter how sick they are? No matter if they’re crying for the first five minutes of it, or if they walk in having active chest pain and you need to get them over to a hospital via ambulance right away? 15 minutes even if they’re asking you to fill out 5 forms that take 5 minutes each? That makes no sense. (Primary care docs certainly care about time, and medical students certainly care about money, just illustrating two of the big issues for primary care today.)

I’d like to discuss each of these issues–money and time–a bit further, because I believe they have wide-reaching consequences on our health care system (since, as we said above, primary care is the foundation of a health care system):

Money. While you might just say, “Well duh, doctors, like everyone else, want more money,” it’s more significant than this. We pay doctors a certain amount based on what they do. Medicare sets these amounts, and most insurers use Medicare’s rates on which to base their own. The way that we pay physicians today, doing is rewarded much more than thinking is. Extreme example: A doctor who performs a surgery is paid much more than another doctor who sees a child for a rash and knows the rash will soon go away, since it’s just a virus. An even more real-life example: a physician gets to bill for a more complex visit (and better-paying one) by prescribing a medicine over not prescribing one. We wonder, “Gosh, why do patients always want something done–a blood test, a study, a scan–when often watchful waiting is the better choice for the patient?” Culture is certainly to blame, but perhaps so are doctors. Patients have learned that more (tests, studies, scans) is better because more is better: for physicians’ pocketbooks. There’s a clear incentive in the system for doctors to do more, so perhaps patients have just learned that more is better by watching us to begin with. (See this NYT article for a perfect example of “more is better.”) I’m not suggesting doctors do this consciously, or that this is the only reason, just one that should be considered as it has drastic consequences for health care costs and unnecessary procedures that unnecessarily place patients at risk.

Time. Borrowing this point from the Panda Bear: when doctors only get 15 minutes to see a patient, you leave them no choice but to start referring a patient out to specialty care when often the diagnosis just requires a bit more time to sniff out. A few more questions to come to the right one. But instead, in this system where each patient only gets 15 minutes of a doctor’s time per visit, everything is referred to a specialist (who often either gets a bit more time to see each patient, or at least is just dealing with one single issue). Can any adult medicine doctor manage someone’s heart failure leg edema? Sure! But put the heart failure in a 75 year-old with glaucoma, dry skin, lung cancer, diabetes, and peripheral neuropathy, and it’s no wonder someone might say “Hey, go see a cardiologist about your leg swelling, I’ve got enough other problems to fix.” This not only leads to increased health care costs from unnecessary specialist care, but also leads to patient confusion (why am I seeing ANOTHER doctor?). I just read some study (can’t find it) linked somewhere saying that most specialists get referrals from primary care doctors without ANY documentation of why the patient is being refered? Perhaps there’s no time for the primary care doctor to write up the referral?

One can look at concierge medicine, which I discuss here and here, as symptoms of this lack of time and money problem. Thanks to Roy Poses for this analogy.

In typical Over My Med Body style, I think we need to address the root concerns identified above: time and money. Lack of primary care affects us all. (We Are All Connected.) I’m probably going to piss off both primary care doctors and specialists with my suggestions here, so please, leave your two cents on how these ideas might be improved.

Money: The simple answer is “pay primary care doctors more.” I believe this should be at the expense of specialists, meaning that the gap between specialists and primary care doctors’ incomes should shrink. Primary care is an incredibly challenging field–one of the most, in fact–and doctors should be better-compensated for practicing it. Perhaps, as well, they should be rewarded for good long-term outcomes for their patients.

Another idea I’d like to float down the river: pay primary care doctors per hour, like lawyers, instead of per patient, with minimums and maximums based on a patient’s comorbidities. So if a patient takes 15 minutes to see and 5 minutes to document, and another 5 minutes to arrange a CT scan for, the doctor gets paid for all 25 minutes (currently they only get paid for the 15 minute visit). All other doctors would still only receive payment for the 15 minutes to see a patient. I’ve suggested this idea before–pay primary care doctors for their paperwork–and I think it would pay primary care doctors better, allow them to provide better care for their patients, and encourage more medical students, residents, and other already-trained doctors to go into the field.

Time: Simply, doctors need to be given more time to see more complex patients. With the 15 minute system we’re in today, I think it has had the effect of trimming the fat from the patient visit, but it leaves little to no room for patient complexity or severity of illness.

I do think also that there are plenty of primary care options that should be open to nurse practioners and physician assistants. There are lots of circumstances where a patient needs to be seen by a doctor, but if the diagnosis is viral upper respiratory infection, why not allow a physician assistant to reassure a patient? I have trouble seeing the other side of this argument.

Medical students spend an average of $139,000 on medical school in the United States, while other nations provide either fully-funded medical school education or at least greatly subsidized medical education. When you add in the costs of an undergradate degree (which is often either not necessary for other countries’ medical school admission or again tax payer-funded), it’s not uncommon to have medical students starting residency in $200,000 of educational debt.

Often medical students also need to purchase or own a car in order to work at the multiple hospitals which will comprise their clinical training. This adds significantly to their expenses (as they have to take out separate car loans at higher interest rates than most of their student loans, and any car loan debts they have get subtracted from their eligible financial aid amount as well). In order to match in certain specialties, students may have to apply to 50 or more programs and interview at a huge number of them. This enormous amount spent applying, booking flights and hotel rooms and meals on the road can easily add up to $10,000 — and unless the student has $10,000 sitting around, it all goes on the credit card, at an even higher interest rate.

Because interest accrues immediately following graduation, even a low interest loan at 2-3% grows quickly when the principal is $100,000 or $200,000.

While these are just numbers on a piece of paper for most of us medical students (translation: I can’t really fathom owing $200,000, so I just pretend it doesn’t exist), we understand it well deep in our financial souls. Most medical students would be lying if they said this doesn’t at all cross their minds when they consider a specialty and future salary. Being in the hole $200,000 is a gigantic Sword of Damacles that scares the crap out of me.

As I’ve said before, i would much rather have medical school be free (read: tax-payer financed) and either have an expectation of:

making less money after residency or

required service time to the taxpayers who financed my education

Maybe we make it a choice. You can choose to pay full price, or pay no price, with either a guarantee that you make less money for life or have required service time for the country.*

I know the government has made unsuccessful attempts to do this in the past by essentially providing too little of a sudsidy for physicians; I would recommend improving this strategy by altering tuition reimbursement based on specialty need and location served. (For example, a primary care physician working in a rural area might be reimbursed 75% of tuition per year, while a pediatrician in the Bronx might be reimbursed 60%.) Perhaps physicians who continue to practice in these settings might receive bonuses for 5 years served, 10 years served, etc. (Yes, I realize the military does offer some programs like this for tuition reimbursement, however it is not available to some physicians *ahem, me* because of don’t ask, don’t tell.)

* Many medical training programs in other countries already require their trainees to essentially complete a medical internship in a rural or underserved area of their country where they are the doctor for the entire community; only then can they go on to specialize in surgery, radiology, obstetrics and gynecology, etc.

HIPAA is like the Transportation Safety Administration’s requirements that everyone take off their shoes and only carry a quart of liquids and creams: it apparently makes us feel safe and protected, but really just it’s all a big pony show that wastes everyone’s time.

The idea of HIPAA’s privacy rules is this: health information is private. It’s nobody’s beeswax besides yours, your doctor’s, and whoever’s agreed to pay for your care (insure you). And I agree. It is nobody’s beeswax. But it’s so bogusly enforced that it just creates headaches. As I’ve said before, I could easily walk into any hospital in the United States, and dressed appropriately, start reading anyone’s paper chart. Guaranteed. So, see, your health information isn’t private. It should be, but it isn’t.

HIPAA also prevents information from being shared between physician and patient easily electronically. HIPAA lists 18 items that must be protected and cannot be included unless the information is transmitted securely. (Note to bloggers: this is why I change everything about my patients if I write about them: saying anything more specific than what state you’re in is Protected Health Information!) Patients clearly want the ability to electronically talk to their physicians; my generation of physicians would certainly want this as well. Quick question, or side effects of a medication becoming a problem? Want a list of your medications? Want lab results emailed to you? Want your physician to email you an appointment reminder? No no no no no. Instead, we have systems where your doctor sends a message to you in a system with ANOTHER username and ANOTHER password, and it’s a big headache. Even if it’s not that bad of a system, you don’t have access to the messages on your own computer. It’s not like an email that you can just go back and find the message.

What’s even more ridiculous is that HIPAA doesn’t apply to anyone that’s not providing health care or paying for it. So neither Google nor Microsoft even have to comply with any of these requirements, so they’re more free to make information exchange happen than your own physicians!

Make HIPAA opt-outable easily. Maybe this is already common thing, but I haven’t really seen it anywhere. A simple form: I hereby authorize Dr. Walker to unsecurely email me with my: ___ Medications ___ Lab Results ___ Diagnoses to blah@blah.com, and waive my right to HIPAA security protections.

Also: pay doctors for email consults. When in doubt, the physician should always bring the patient in, but it’s a waste of both the physician’s time and the patient’s for questions like, “I feel better, do I need to finish my antibiotics?”

Be consistent with privacy rules. Either require all hospitals to go electronic so that data is behind a password (although one could certainly argue that it’s even easier to steal more data more quickly electronically) or don’t be so damn ridiculous about privacy standards. Also in exchange, provide a more standard protocol to streamline the reporting of stolen identities and stolen health records.

These terms are often thrown around as synonymous, when they clearly are not. Someone’s, or some society’s health takes into consideration the freedom from illness, disease, or injury (actually from the Germanic meaning “wholeness”). Health is impacted by genetics, stress, violence, diet, laws, living standards, and health care, to name a few.

“Health care” is the interventions we perform on individuals to try to keep them healthy. Economically, “health care” is resources spent on health: not just monetary resources, but time, energy, workforce, etc.

Health insurance is a way to pay for health care. The theory behind insurance is this: big, bad, expensive things can happen to you at any time. Your house can catch fire. You can get into a car accident. You can get cancer. We pay for insurance to decrease this risk–that we pay into the system now so that it will bail us out later. The more people in this system, the better. If there’s only two people, and one gets robbed, there goes a lot of the other guy’s money! But if 100 people are in the system, there’s 99 people’s money left to even out the risk.

The goal of health policy is to make the population as healthy as possible.

The goal of health care policy is to make the health care system — only one part of the determinants of health — as “good” at divvying up limited health care resources as possible. (Lots of ways to define good. I define it as going to those who most need them.)

I would love to see a population whose health is so darn good that we wouldn’t have to worry as much about health care. Health alone could be its own blog, so I’ll simply suggest a few ways that we might be healthier, without even messing with health care:

Reverse the subsidies for vegetables versus meat. Wonder why a salad costs more than a Big Mac? It’s not that cows are cheap. It’s that government subsidizes.

Walking instead of driving. Afraid as Americans we screwed the pooch on this one during white flight and suburban sprawl of the mid-20th century. One of many reasons I prefer the city.

Create a more equal society. It should be no surprise to anyone that the poor are the earliest to die and are the most obese. When your food options are canned foods or McDonald’s, the game’s already against you.

I illustrate these points only to remind you that if your goal is to make people healthier, there’s many, many more avenues that might be far more effective (and far far cheaper) than optimizing or fixing the health care system. (We just like to argue about it because it’s the most accessible and well-understood by us.)

We’re all in this thing together, whatever it is. That “limited resources” bit you remember from Econ 101? It applies to health care, too.

Look, the lesser argument has been made many times over, by the likes of Paul Farmer and other radicals who have fought battles in Infectious Disease: that if we don’t control infections in one population, they spread to other populations and make us all sicker. That if we don’t treat multi-drug resistant TB in Haiti, Peru, or the prisons of Russia, then we Americans will be fighting the MDR-TB here at home. (Similarly in the infectious disease world is the fact that vaccine “herd immunity” is becoming less useful, as our international lifestyles put us into contact with people who were born outside the US and never got measles vaccines, for example, and may be contagious.)

But the greater argument for our interconnectedness is this: that by allowing whole swarms of people (often but not always the un- or under-insured) to go without necessary chronic care and necessary follow-up, they eventually become sicker and more complex. And this, my friends, creates problems for all of us. Because sicker and more complex patients require more doctors and more time and more hospitalizations. And more hospitalizations that take more time, because sicker and more complex patients have more things that will go wrong with them.

How does this get back to you, oh-self-concerned one? Because when there’s more sick patients, there’s less time for you, when you’re sick. Some say that patients will get worse care and will be seen slower in the Emergency Department. While this may be true to some extent, triage — the sickest people to the front of the line — often takes care of much of this. But because there’s simple more people (quantity, not necessarily quality), your mom with the broken hip is seen slower, and fewer minutes are spent on her since there’s more patients total. It’s no wonder hospitals are stuffed to capacity.

So take a system with sick people, discourage them from seeking primary care by:

having them pay for primary care when they themselves often don’t see any benefit from it and

discourage doctors from going into primary care by making it a nightmare of:

paperwork

referrals

tons of complex, sick patients to be seen in 15 minutes and

little pay compared to other doctors

And you’ve got what we have today: any number of people who are sick, complex, and take up tons of time, energy and resources. And no matter how you spin it, it ends up creating worse care for us all.

We as doctors tell our patients to do certain things to stay healthy — and often pay more money to buy these pills – when often patients don’t see one lick of good from our recommendations. All they see is a lower blood pressure number, and money out of their pockets for expensive pills. (That is, until they stop taking their pills, or have a really bad consequence of their disease, then they see it.) Throw in any number of health care and physician scandals in the past decade, and it’s no wonder they’re skeptical.

In order for us to receive better care and to fight the constant ambulance diversions and hospital overflows, we’ve got to ensure that people take care of themselves. And that starts by removing the barriers to self-care.

New Zealand is the only other country in the world that allows direct-to-consumer marketing. Those Lipitor ads, the Mucinex boogers — they don’t exist outside of those two countries. The pharmaceutical companies claim that their advertisements provide important educational value to patients. “They can learn about diseases they might have!” the companies say. I say humbug.

Patients learn nothing from these ads, besides seeing ridiculously attractive, healthy-looking, active people pretend to have any number of diseases. I’ve said it before–if the companies were truly interested in educating patients, they would teach them about any number of topics that many patients do not understand. Instead, they hawk products half the time and quickly ramble a list of side effects with the other half left.

Remember–the Pharma corporations are responsible to their shareholders, not the public. Their goal is to make more money, by selling more pills. They do not “educate patients” because it’s good for patients. They “educate patients” because it’s better for their bottom line. Do we not trust physicians to make accurate diagnoses that we need patients to ask for Lipitor?

Ban direct-to-consumer advertising.

If not that, make the field “direct-to-consumer educatisng.” 95% of your advertising time teaches the public how scientific studies work, or what a cardiac stress test does, or why antibiotic resistance is a problem and why doctors don’t like to give out antibiotics liberally, or why CT scans aren’t always a good idea, or why vaccines are safe. There’s an almost limitless number of topics physicians are repeating over and over to patients. In the last 5 seconds, you get to flash your drug logo. “Brought to you by Pfizer.” Put out or get out.

Even before the 80-hour work week, shift work was part of a physician’s and resident’s training. Now, it’s just more prominent. Residency programs have adapted, introducing night teams for their patients, various types of “floats” (night, day, root beer) who take over for a resident–or often an entire team of residents–when one set must go home because of hour restrictions.

In some ways, this is a good adaptation — and even if it’s not, it seems to be staying. I don’t care how tough and hardcore you are, you wouldn’t want a sleep-deprived resident (equivalent to an intoxicated resident) making health care decisions about your mother, let alone operating on her. (Having alcohol while on call or in the hospital would be a major violation, but sleep deprivation is inherently part of the system. Funny.)

In other ways, shift work is bad for patients: I know Mrs. Jones much better than the colleague I’m signing her out to, because she’s told me her whole story, her emergency contact, and how to reach her daughter’s cell phone if the first three numbers don’t work. Thoroughly complicating this issue is hospital overcrowding, especially in the ED when patients can be waiting for beds for days, and end up being handed off to a new physician every 8 hours. This knowledge differential between my colleague and I — he coming on shift, me going off shift — somehow must change, because the shift work world isn’t going to. Younger physicians are wanting shift work.

We know that most errors come about through errors of communication and often during shift changes. We KNOW that.

We owe it to our patients that we safely and correctly do hand-offs. We should be relying on a system that is designed to minimize communication errors, prioritize information and patients, and eliminate ambiguity while being as efficient as possible.

I’m not exactly sure what this system looks like. Maybe it means that we have some computer system that somehow collects important information about the patient and puts together a summary based on the electronic medical record.

I certainly know when I come across a piece of information that I know will be vital to sign-out, but sometimes I struggle at signout to remember it. Maybe it means that we carry around voice recorders and make memos to ourselves.

Maybe it means that we follow a cue from the nursing playbook and devote an hour to “shift change” in the name of patient safety. We review the patients in order of severity or likelihood something will come up, and in an order of importance: Patient Name, Age, Admission Diagnosis, Code Status, Active Problems, Active Plan, Anticipatory Guidance.

Maybe it means we teach physicians about conditional orders, and allow them to be carried out even if the physician is signed out. Things like:

IF
(Troponin #3 = Normal AND
Social Work Note AND
Dispo = Complete AND
Patient Has Outpatient Medications Ready AND
IV is out)
THEN
(discharge home)

I’m not a communications expert, and I’ve fallen too far down the rabbit hole to probably even see where my own communication errors are. Perhaps that’s the problem right there — we don’t even know when or how we failed. Maybe the first step is to discuss it happening: along with M&M, how about a communication version? W&W? Words and Warnings?

As I’ll repeat throughout this series: if we as physicians don’t step up to the plate and do something about it ourselves, someone else will. And often that “someone else” isn’t caring for patients and doesn’t know what they’re doing. Being proactive about this stuff will help us in the long run.

A number of services like HealthGrades and RateMDs allow patients to rate their doctors. Most of these ratings are based on things like “ease of scheduling an office visit,” “Wait time before seeing the physician,” or “Helps patients understand their medical conditions.” Fair enough things to grade a physician on.

A number of services like Medicare’s Hospital Compare or Cal Hospital Compare allow patients to compare hopsitals based on a set of standard “quality indicators” for things that we know will help patients do well — things like making sure patients with heart attacks get the right medicines or treatments in the right amount of time, or giving older patients pneumonia vaccines. Not only are hospitals publicly evaluated on these indicators, but Medicare is considering paying hospitals (and doctors) based on standard indicators. This is know as “P4P” or “Pay for Performance.”

However, physicians and hospitals rightfully argue several things:

You’re only going to get the extreme patients to evaluate you (and often the unhappy ones

The unhappy patients will have the opportunity to publicly say how terrible the doctor is, but because of privacy rules, the doctor or hospital cannot comment or defend him or herself

There is too much emphasis on bedside manner and convenience, and not enough information on outcomes — “How Good A Doctor Am I?”

Even if there is information on outcomes (like in the hospitals’ cases) if this determines payment or discourages future patients because of a bad rating of outcomes, the physician will be much less likely to risk treating a very sick patient, who will likely have a bad outcome no matter what

These systems also ignore where a hospital operates or where a doctor works — hospitals with large populations of poor patients are likely to be sicker than hospitals in affluent areas. Academic hospitals which often care for many incredibly complex, sick patients might be compared to relatively straightforward, simple patients at another hospital down the street.

Medicare has run a trial of this P4P stuff, and it’s been written up in the New England Journal, called Pay For Performance: At the Tipping Point. Let’s look at the some of the outcomes — they took hospitals and either paid the hospitals for their quality improvements, or told the hospitals their outcomes would be publicly available online:

Now, some might say, “Wow, look at that, if you pay people for doing better on quality, they get better!” But the keen observer would point something else out: “Wow, even if you don’t pay people, but make results publicly available, people do better, too!”

Folks (and by folks, I mean doctors and hospitals), this stuff isn’t going away. If you don’t have patients blogging about their encounter with you by name, it’s only because they’re in their 20s or 30s and are young and healthy. (I happen to be friends with one Dr. Gilbert, who is mentioned on the Stanford Hospital Yelp page as the Stanford ER’s McDreamy.) Seriously. The personal evaluations about you are coming, whether you like them or not. It’s in our best interests to argue for the best, most objective and accurate standards. If you’re one of the people that says “Medicine is a business above all,” (I’m not) then fine, but look at every other business in the US: it’s getting revolutionized, criticized, and evaluated online.

We don’t need less transparency, we need more. And the only way we’re going to get there is by having more data.

Physicians and hospitals should certainly be judged by if they’re taking good care of their patients. That means a lot of things: patient rapport, having a “good experience” (whatever that means), but more importantly, outcomes and guidelines. These are, however, guidelines, not rules. It should be simple and straightforward for the hospital or physician to not follow a guideline: if the patient’s heart rate is already 40, they shouldn’t be getting a beta blocker, which slows the heart rate, for example.

For physicians: do patients want the gruff surgeon who’s the best, or the one who’s pretty good but is kind and nurturing (I swear, there’s nurturing surgeons out there)? This data will soon be out there–but in subjective form. “I saw Dr. Green and two weeks later, my cancer had metastasized!” We need accurate, fair standards to examine how we’re doing as doctors, that take into consideration things like patient complexity and compare apples to apples.

For hospitals: I think a lot of the P4P and outcomes and quality indicators stuff for hospitals is worthless for the public. Hospitals get patients for primarily two reasons:

The patient comes to the hospital’s ER and gets admitted.

The patient has a particular doctor who has admission privileges at Hospital X, so the patient gets admitted to Hospital X.

Patients, when sick, do not launch a web browser and see which hospital was more likely to give an ACE inhibitor to its diabetics. They go where their doctor tells them, or barring that, wherever is closest or where they’ve had a good experience before.

P4P and Incentives
One of the big concerns in P4P is “how do we define good, and how do we reward that?” Do we pay the doctors who are really crappy, but then start to improve, while ignoring the docs who are already outstanding? Both? Neither?

For physicians: It’s a little frustrating that we would have to pay physicians to practice appropriate medicine, instead of expecting them to simply keep up with modern medicine, no? Isn’t that what CME requirements are for? I’m not talking about the cutting edge, latest-issue-of-NEJM stuff, but stuff that we’ve known for 10 years? ACE inhibitors, beta blockers, aspirin?

For hospitals: It’s a bit more complex to improve indicators in hospitals, because there’s so many different steps involved to coordinate successes, so hospitals should be rewarded handsomely. But hospitals shouldn’t be competing for patients. They should be competing with other hospitals. Perhaps we create “reward funds” for 3 hospital types: community, academic, and county. And hospitals compete with each other for “most improved,” “best indicators, etc,” — again, apples to apples hospital comparisons. Each 6 months, the top hospital in each category gets a reward that gets split up between the hospital and its staff; this would create innovation between hospitals, everyone trying to do better a job. And let’s say the winning hospitals have to give away their secrets to “best pneumonia vaccine rate” to everyone else.

Perhaps for the next 5 years, we start with carrots. If you’re either improving or continuing to do a good job (as compared to your equals), you get a bonus. 5 years after that, if you’re not improving, or doing significantly worse, in comes the stick, with some sort of punishment.

(Look, I’m well aware that the indicators aren’t always practical or the best, and they certainly need to be improved drastically, taking into account the differences between community and academic medical centers, etc, but the evaluations and ratings are coming. I’d much rather setup a system that is created by health care providers and reasonably fair than be evaluated by the subjective masses whose opinions are often muddied by sad, tragic bad outcomes.)

EMTALA, the law that requires ERs to evaluate and stabilize everyone who shows up, is a good law. (There went half my readers right there.) If you’re still with me:

I would argue (as would the writers of EMTALA) that we are so advanced a nation that patients should not be dying on the streets because of their inability to pay for emergency medical care. The problem with EMTALA is that it provides too much potential for abuse. This is the fundamental art of social policy — how do I put together a rule to maximize its use for its intended purposes, yet minimize the opportunities for abuse and loss of personal freedoms for whom the rule applies? (Note: unfortunately many policy makers do not seem to follow or care about this. They trust lobbyists to do this.)

If you were to look online or eavesdrop in a doctor’s lounge, likely “abuse of medical resources by certain patients” would be near the top a frequency-of-complaining list. However if you were to look at how much, in reality, these patients actually cost the system, it would be a tiny percentage of that compared to the truly sick. So it’s more a matter of wasting a doctor’s time and energy — these patients are truly draining: they frustrate physicians and nurses greatly.

The other problem is that EMTALA is an unfunded mandate. This means that hospitals are required to follow the rules of EMTALA no matter what the cost may be to the individual hospital.

Often it depends on why the patient is there — which often is near impossible to discern in the first place. Others are straightforward: hypochrondriacs? Easy. Refer to psych. For drug seekers (note: boy would these patients be easier to spot a mile away if we had some sort of national medical record), make sure they’re only drug-seeking, and get them out.

Others seemingly have nothing better to do. While I’d argue that perhaps job resources, education, and opportunities in the long term and for future generations might be a better solution, I’ll stick to health care for now.

If we want these patients to either stop seeking care altogether (not good to alienate people from the health care system, I’d argue, see my other posts in this series) or start seeking more appropriate care, then we’ve got to use our carrots (rewards) and our sticks (punishments) to lead the donkey.

Maybe we just need to offer better options. For some patients who simply don’t know any better, and for whom a stern lecture by a doctor isn’t going to educate them, they just need another place to go besides the Emergency Department. For these patients, we should be supporting our community health centers for after-hours clinics. They’re usually just as well-placed and located as hospitals, they provide more appropriate care settings at much lower costs, and they would also get a patient tied in for follow-up at the clinic, maybe even start seeing a physician on a regular basis. These after-hours clinics should be funded, like EMTALA (see below).

For other patients, they need a stick, as the niceities of education and better options simply don’t appeal to their finer sensibilities. Two possibilities here: perhaps it’s three strikes out at the olllld ballll game. Once a patient has been seen for non-urgent care (which would obviously need to be defined) three times, they no longer qualify for EMTALA at the hospital. If they return, they get a vital signs screening by a triage nurse, and barring no abnormal vitals or other gross, obvious issues, they are turned away. Another possibility would be charging a patient for non-urgent issues. We say, “Sure, we’re happy to evaluate you,” but if you are not even urgent (remember, you’re at an Emergency Department), you’ll be charged. (Note: this latter option I don’t support if there are no other options for these patients, which is why I think we should offer after-hours clinics.)

Finally, funding. A colleague of mine likes to say that a heavenly program can be hell if not funded appropriately, and maybe this would lead to a chain reaction of EMTALA fixes. If the federal government (read: taxpayers) had to start paying for EMTALA care (note: we already are, in the prices of higher costs to subsidize unreimbursed care), we would immediately see the true costs, and take actions to fix it. Currently, it’s all just buried in inflated prices and percentages of costs and losses in hospital account ledgers. Either way, EMTALA care needs to be funded. Some states are trying to partially fund this effort by passing certain taxes, but a national source makes more sense, since it’s a national law.

(Note: “Repeal EMTALA” enthusiasts are either kidding themselves, heartless, or living on Mars. If you believe that Emergency Departments in the United States should check for insurance in the ambulance bay or require a funds verification before they see a septic patient or one after a bad car accident, like they do in India, you might as well stop reading. We’re not going to see eye-to-eye anyway. For-profit hospitals would have no problem doing this, and it’s unethical and immoral.)

Over the next 30 years, America is going to be seeing its population growing in the older age groups more than the younger ones. We will see a massive increase in our elderly population, who tend to be sicker, have more chronic diseases complicating their care, and have weaker immune systems, making them more likely to get sick with an infection in the first place. And as people will be living longer, they will have increased years for possible health expenditures, including medical interventions that may or may not be necessary.

At present, our health care system already appears to be unable to handle this load of patients. It will not improve with a higher quantity of patients. While we can certainly build more beds and more hospitals, we run into a more serious supply problem: doctors and nurses to staff them. (Taking Jack Wennberg’s Dartmouth Atlas of Health Care only complicated the issue further, showing that less health care = healther patients, that there are huge regional variations in care patterns with little change in outcomes by region, and that 30% of Medicare’s budget is spent on the last year of someone’s life.)

We also currently have a system where, due to legal fears (and the fact that Medicare will pay for it), doctors and hospitals end up providing ultimately futile care (ie: using health care resources that will not ever be able to meet the goals of care for a patient) due to either a) lack of an advance directive stating the patient’s wishes, b) family disagreement over the patient’s wishes, with threats of a lawsuit, and c) no standard by which to determine how to proceed in these situations. This is often ultimately bad for the patient, and is certainly not without harm: all interventions carry risk, and most cause at least some degree of pain or discomfort. Add in the oft-quoted Hospice statistic that while 90% of patients, when asked, want to die at home, 90% currently die out-of-home.

I’m certainly not ready to say that “at age 80, you get no more health care, and if you die, you die” as some have proposed. If you spend even a day in a hospital or medical clinic you see the broad, broad variation of what 80 means. 80 can be fully, 100% functional, with energy and vibrance of a 25 year-old; 80 can mean severe, advanced Alzheimer’s with 3 heart attacks and the inability to dress or feed oneself.

What we need is a better prognosticator. Some way to figure out when a person’s last year of life will be. (I worry this may never come; we humans are just too damn unique, complex, and confusing, and the awesome human spirit often beats the actuarial tables in the betting game.)

In one corner, we have the elderly patient. He doesn’t want, in general, to die in a hospial, connected to ICU tubes, fingers and tubes in every orifice. It is not a dignified death. In fact, in retrospect, when most people finally learn about and enroll in hospice, their reaction is “I wish we would have known about this sooner.” In the other corner, we have the health care system, which can’t figure out how to balance the needs of society. So what do we do? We do what any American would do: we offer choice.

Experiment: we offer people, say, 90 and above $30,000 and 100% free hospice care. In exchange, they agree to seek simple or comfort care only. See, those “last 6 months” costs or “last 1 year” costs are worth real, American dollars. And my guess is if you ask these people what they want with their final time, it’s not to spend it in a hospital or a doctor’s office. Maybe it’s to see Italy or France. Or to take a vacation with their great-grandchildren to Disneyworld. Or buy a fast car. Or invest it in the stock market. Who knows? I certainly don’t pretend to know what you want.

Again, this would not be a Draconian requirement, merely an option. If you’re going to be spending your hard-earned insurance dollars on something, perhaps you should get a choice–hospital food and IV sticks daily, or Paris? Sure, maybe you die a little sooner because you’re not seeing every doctor every month, but we certainly allow people to die sooner by smoking cigarettes or ride a bike without a helmet, right?

Even if this isn’t the option you choose, I strongly believe that Hospice should be free. Not only because it’s a simple, humane, dignified, cost-effective way to provide closure to people’s lives, but that it is what most people want at the end of life. It makes people comfortable and addresses their symptoms while giving them the needed medical follow-up to meet the goals they want for their short time remaining: often peace, closure, and time with the ones they love.

Second, I believe everyone with Medicare (or perhaps everyone with insurance, or everyone admitted to the hospital?) must have an advance directive. Even if it’s “I want everything done,” everyone must have something. Say we tell everyone they must have one by 2010, and if they have one by 2009, they get an extra $200 tax credit (first carrot, then stick). There are too many people who ignore the fact that they will die (see above: everyone does) and it causes problems for the entire society. (Remember, we’re all in this together.) From the family members it tears apart to the doctors and nurses who feel they are providing futile care, to your loved one who needs a hospital bed but cannot get one because the hospital is full. I believe we are truly disrespecting and taking the dignity from our loved ones by not knowing what they would want. We owe it to our parents, spouses, and loved ones to be able to represent them and their wishes correctly. We’ve now had ventilators and life support systems for what, 50 years? — but we still can’t seem to face up to the fact that many of our loved ones will spend time incapacitated at some point in their lives and we should know what to do when they are.

Third, we must recognize that often, family bickering about what a parent or other loved one “would have wanted” is not truly bickering, but more often a stage in the grief process — denial (“Mom is not going to die, do everything!”), anger (“How *dare* you say that mom is dying! Do everything!”) or bargaining (“Can we just try chemotherapy for two more weeks? Do everything!”). If we understand them from this perspective, it may be easier to resolve these issues.

Note: I toyed with the idea of “cost-sharing” for futile care, but I believe this to be a cruel way of enforcing policy–that “mom is going to die because I can’t afford to pay for her care.” I’d much rather setup a system that makes it “okay” for mom to die than “forcing” her to die. (See my upcoming post on Patient Autonomy.)

Finally, language affects the way we understand our world. I wholely support the efforts to change terms “do not resuscitate” to “allow natural death,” and “life support” to “artificial organ support,” as often our tools are merely preserving organs, not a patient’s life. As Reverend Chuck Meyer discusses the former terms:

An order to Allow Natural Death is meant to ensure that only comfort measures are provided. By using the AND, physicians and other medical professionals would be acknowledging that the person is dying and that everything that is being done for the patient–including the withdrawal of nutrition and hydration–will allow the dying process to occur as comfortably as possible. While a DNR patient in Intensive Care might be put on a ventilator, given artificial hydration, or have a feeding tube inserted, an AND patient would have all of those things withdrawn, discontinued, or not even started, since such treatments are painful and burdensome for the terminally ill. The AND would prevent this unintentional pain and simply Allow a Natural Death.

Welcome to “Health Care’s Broke,” my series of thoughts on what’s ailing the health care system, and what needs to happen to solve the problems we’ll face in the next century, as we face an aging population and workforce, a changing physician workforce, and new technologies and therapies that improve the lives of patients. Our health care system was created to deal with the acute illnesses, while our patients and providers now deal with chronic ones. Our health care system — and few others in the world — have adapted in response.

I’ll be tackling everything from health care financing to HIPAA and privacy, from malpractice to direct-to-consumer marketing, and everything in between.

The goal? To create some constructive dialog from both sides of the political aisle on what should happen. And to that end, I welcome your comments, but only if they’re of a constructive nature. While my undergraduate background was in Health Policy, and my graduate training is in Medicine, I make no claims to be the ultimate in health wonkery. To that end, I’d love to hear why you think my ideas would or wouldn’t work, or how they might be improved. They are, to some degree, brainstorms straight from the Half-Bakery, and while I think many are unique or different from what’s already been tried or suggested, maybe they’re brilliant. Maybe they’re idiotic. I am simply trying to understand why each of the players in the health care system act/behave as they do, and then provide possible fixes based on these motivations.

I’ll be posting one to two topics a day, if I can keep up. (I already have 9 written.) I look forward to the dialog. My goal is to keep it as apolitical as possible, focusing on the health care side of things as much as possible. But again. It isn’t a political diatribe. It’s a series of reasoned arguments to provide health care resources to those who most need them.

The perspective I take here is a mix of wonk and physician. In some areas, I may see more of the individual physician’s or patient’s perspective. In others, I may look more toward what would be best for society, not best for each individual person: patient or physician.

I am also a firm believer in the fact that if we do not make efforts to change, progress, and improve in areas that we know can and need to be improved, Congress or JCAHO or some other regulatory body will step in and pass some probably-well-meaning but ultimately-terrible-for-docs-and-patients law to try to remedy the problem themselves. Privacy was a concern of patients, doctors didn’t do enough to self-regulate, and we got hit with the hell that is HIPAA.

Regulatory bodies and Congress are, for the most part, reactionary. If a problem comes up, and is not solved, they will respond by imposing regulations. Look at any JCAHO regulation, and I guarantee there’s a history behind it. Do I think that a nurse and a doctor can’t talk to each other over the phone without a verbal readback by the nurse? Of course not. But somewhere along the way, enough verbal orders got screwed up that someone decided to do something about it. Why do chart regulations now stipulate that you have to write out morphine, instead of MSO4? Because doctors’ handwriting was bad enough that people were getting magnesium instead. I dislike regulations entirely, and don’t believe that an administrator at a desk knows more than I do about taking care of the patient in front of me, but if those of us in health care aren’t critical of ourselves in figuring out what’s going wrong and how we can fix it, inane, silly, wasteful and potentially dangerous regulations will keep coming down the pipeline.

I do not believe that just because doctors mostly control health care (really, we do) we have the right to be stuck in our ways while every other industry adapts and progresses. I understand the reasons behind stuck-in-our-ways, but they seem to be a bit out of sync with the 21st century.

Why Am I Doing This?

We spend plenty of time debating health care financing (which is certainly important), but as many people have already noted, we have many other major issues in health care that aren’t being addressed or even discussed. While Americans view health care as a major issue, the presidential candidates (and politicians in general) have largely ignored anything besides health care financing. So I figured I might as well try to do something about it.

(Note: if you’re interested in linking to this series, I’d love the help getting the discussion going! Copy this code below to your blog, and it’ll link to the category archive with the image and look like this: